Provider Demographics
NPI:1295270452
Name:GREEN, PRISCILLA
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10312 BLOOMINGDALE AVE
Mailing Address - Street 2:STE 108 PMB 348
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-3663
Mailing Address - Country:US
Mailing Address - Phone:813-863-3717
Mailing Address - Fax:813-354-4547
Practice Address - Street 1:412 E MADISON ST STE 1206
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-4619
Practice Address - Country:US
Practice Address - Phone:813-863-6762
Practice Address - Fax:813-354-4547
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL1300174463343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)